Many women with large and/or sagging breasts (sagging is called “ptosis” by doctors) who are diagnosed with breast cancer or want to have preventive mastectomy because they are at high risk of breast cancer aren’t considered good candidates for nipple-sparing mastectomy followed by autologous or “flap” reconstruction. Autologous reconstruction means that tissue from another part of your body -- usually the belly, the back, buttocks, or inner thighs -- is moved to the breast area and shaped into a breast. TRAM and DIEP flaps are examples of autologous reconstruction.

In nipple-sparing mastectomy, all of the breast tissue is removed, but the nipple is left alone. In women with large or sagging breasts, it has been difficult for surgeons to correctly position the nipple during autologous reconstruction. In some cases the tissue of the nipple also starts to die because it doesn’t have an adequate blood supply.

So in many cases, the only surgical and reconstruction option for women with large or sagging breasts is to have the entire breast, including the nipple, removed and then have reconstruction with an implant.

A study has found doing a full breast lift 3 or more months after autologous reconstruction on women with large or sagging breasts who had nipple-sparing mastectomy followed by immediate DIEP, SGAP, stacked DIEP, or stacked DIEP + SGAP flaps allows for good nipple placement and a healthy blood supply to the nipple. This technique may allow more women to have nipple-sparing mastectomy followed by autologous reconstruction.

Perforator flap reconstruction means that the flap of tissue used to rebuild your breast uses an artery perforator, a blood vessel that runs through your abdomen or buttocks. In a DIEP flap, the deep inferior epigastric artery perforator is used. In an SGAP flap, the superior gluteal artery perforator is used. In a stacked DIEP flap, the surgeon either takes two pieces of tissue and “stacks” them to make the breast shape or folds one flap in half to provide the volume that is needed.

Frank DellaCroce, M.D.; Scott Sullivan, M.D.; and Alan Stolier, M.D. are three of the study’s authors. All are surgeons at the Center for Restorative Breast Surgery and all are members of the Breastcancer.org Professional Advisory Board.

In the study, the researchers identified a group of 70 women with moderate to severe sagging breasts who had nipple-sparing mastectomy immediately followed by DIEP, SGAP, stacked DIEP, or stacked DIEP + SGAP reconstruction. All the women had a full breast lift that included nipple-areola repositioning 3 to 6 months or more after reconstruction surgery.

The women ranged from 34 to 66 years old:

nine women had high blood pressure

six had hypothyroidism

six had asthma

one had diabetes

three had lost a large amount of weight

19 had an abnormal BRCA1 or BRCA2 gene

Breast characteristics were:

100 of the breasts had moderate sagging

10 breasts had severe sagging

62 breasts were reconstructed with a DIEP flap

40 breasts were reconstructed with an SGAP flap

13 breasts were reconstructed with a stacked DIEP flap

14 breasts were reconstructed with stacked DIEP + SGAP flaps

eight of the breasts had previously had a lumpectomy and five of these had been treated with radiation therapy

In all cases, the nipples were repositioned correctly and had an adequate blood supply.

After the full breast lift, all the women reported that they had better nipple position and less breast sagging, including the women with severely sagging breasts. All the women also said that they would have the same surgery again because they were so satisfied with the results.

“Implant reconstructions outweigh natural tissue reconstruction by nearly five times in the United States, and some of that is because we don’t do a good enough job of informing women of what is possible with living fat transplant procedures,” said Dr. DellaCroce. “No one thought this was possible before now, and the importance of this discovery cannot be overstated. As nipple-sparing mastectomy becomes more common, we can now offer the same extraordinary outcomes to women with drooping breasts or those with very large breasts. These women, who were previously denied nipple sparing mastectomy due to poor nipple position, can now have a full breast lift or reduction as a part of their overall surgery while still protecting their natural nipple. The key point that women must understand, is that this is impossible to accomplish with an implant reconstruction, but completely possible with a microsurgical flap reconstruction.”

Deciding whether to have a breast reconstructed after surgery to remove breast cancer or after preventive mastectomy is a very personal choice. If you’re planning your surgery, you may decide not to have reconstruction, but it can be helpful to consider all your options.

Here are some questions you might want to think about as you're making your decision about breast reconstruction:

Is it important to you to have a permanent breast shape? Some women prefer to wear a prosthesis instead of having reconstruction.

Is it important to you that your breasts look balanced when wearing a bra and bathing suit? Though you'll be able to see the difference between the rebuilt breast and your other breast when you're naked, reconstruction usually looks very natural when you're wearing a bra or bathing suit.

In your unique situation, will breast reconstruction involve several surgeries over a long period of time? For many women, the answer is yes.

Will your insurance pay for all the reconstruction procedures? Find out what your insurance company will cover.

Did you have a lumpectomy that gave your breast a very different shape than it originally had? If you had a large portion of tissue removed, you might want to have reconstruction to restore a more balanced look.

Do you have any other medical conditions that might affect your ability to heal after surgery? If you have diabetes, circulatory problems, or a bleeding disorder, it may take your body longer to heal from reconstruction surgery than someone who doesn't have these conditions.

Do you have a condition that might give you a distorted image of your body? If you've been diagnosed with anorexia or bulimia, you may have a hard time accepting how your body looks in general, which may make it hard to accept how your reconstructed breast looks.

For more information, including types of reconstruction and the timing of reconstruction, visit the Breastcancer.org Breast Reconstruction section.